Process for Adherence Counseling[1]

  1. Make an introductory statement
    Make a statement acknowledging that experiencing difficulties with taking antiretrovirals (ARVs) is common and in fact inevitable at some point in treatment. State that one role of the clinician is to help identify these difficulties, and to try to make it easier for patients to take their medication. The following is one example among many that can be used:

“Taking pills every day is really hard. Most people have problems taking their pills at some point during treatment. I am going to ask you about problems that you have had taking your pills. Please feel comfortable telling me about pills you may have missed or taken late; I am asking because I want to make it easier for you to take them.”

  1. Confirm understanding of regimen
    Using a visual aid, such as a chart that shows color images of the available antiretroviral pills, ask patients which medications they are taking. For each of the indicated pills, ask how many of them they are taking and how often they are taking them. Ask if they have special instructions for any of the pills, such as dietary restrictions or extra fluid requirements. If any answers are incorrect, it is important at this time to focus on clarifying the regimen prior to completing the adherence assessment.
  1. Assess adherence
    Ask patients about their adherence practices over the past 3 days, 1 day at a time. Start with the day prior to the interview (i.e., yesterday), and ask them how many of their pills they had missed or taken late that day. Then ask about the 2 days prior to that, addressing each day separately. Next, ask about how many doses they had missed or taken late over the past 7 days, and then past 30 days. If they report no missing doses, ask them how long it has been since a dose was missed. Alternatively, a visual analogue scale (VAS) can be used to assess recent adherence using a more simple visual scale.
  1. Ask about reasons for missing doses
    For patients who report missing any dose, ask them if they know the reasons why they missed it/them. Prompt patients if they cannot offer an explanation.Common reasons why people miss medications include simply forgetting, being away from home, being too busy with other things, having a schedule change, experiencing too many side effects from the pills, feeling sick or depressed, and running out of pills.
  1. Ask about medication side effects or other problems
    Ask patients about medication side effects or other problems that they may be experiencing. Prompts can be offered, such as asking whether they have experienced nausea, diarrhea, difficulty with swallowing pills, headaches, fatigue, depression, or any other physical or emotional complaints.
  1. Collaborate with patients to facilitate adherence
    Reassure patients again that problems with adherence are common. Explain that your concern is based on the fact that missing more than 5–10% of the doses in a month (e.g., more than 3–6 doses in a month in a twice-daily regimen) can lead to the medications not working well anymore, and that missing less than this would be a good goal.
  • Take seriously all complaints about side effects or other physical and/or emotional problems, and address them concretely.
  • Offer suggestions to overcome specific obstacles patients may have mentioned, such as using a watch alarm, using a medication organizer, keeping extra packages of pills at work or in the car, or carrying an unmarked bottle for enhanced privacy. Ask patients if they have any ideas of their own to make it easier to take the medications.
  • Finally, do not worry if the problem cannot be solved immediately.Uncovering a problem with adherence is an important accomplishment, and solutions can evolve in subsequent visits.

Process for Adherence Counseling1

I-TECH Clinical Mentoring Toolkit

[1]From Machtinger EL and Bangsberg DR. Adherence to HIV Antiretroviral Therapy, in The HIV InSite Knowledge Base, copyright 2008, Regents of the University of California. Adapted from:Chesney MA, Ickovics JR, Chambers DB, Gifford AL, Neidig J, Zwickl B, Wu AW. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG). AIDS Care 2000; 12:255-66.